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Why use LAMA/LABAs as initial maintenance therapy in specific COPD patients without asthmatic features?



NICE recommendations are based on the LAMA/LABA class of medicines. NICE do not endorse a particular medicine within the class.

Relevant prescribing information for GSK products can be found at the bottom of this webpage.
LAMA/LABAs are indicated as maintenance bronchodilator treatments to relieve symptoms in adult patients with COPD

Long-acting muscarinic antagonists (LAMA) are effective for treating the symptoms of COPD both as monotherapy or as part of a combination therapy alongside a long acting beta2-agonist (LABA)1.

NICE recommend using a combination of a long-acting β2-agonist (LABA) and long-acting muscarinic antagonists (LAMA) as an initial maintenance therapy for appropriate COPD patients. These are people who2:

  • Have spirometrically confirmed COPD and2
  • do not have asthmatic features/features suggesting steroid responsiveness and2
  • remain breathless or have exacerbations despite2
    1. having used or been offered treatment for tobacco dependence if they smoke and
    2. optimised non-pharmacological management and relevant vaccinations and
    3. using a short-acting bronchodilator

Asthmatic features that suggest steroid responsiveness are defined by NICE as2:

  • History of atopy or previous diagnosis of asthma
  • High blood eosinophil count
  • A change of 400ml or more FEV1 (i.e. substantial variation over time)
  • A diurnal change of at least 20% of peak expiratory flow

The NICE recommendations are associated with a UK-based cost effectiveness analysis. This has indicated that LAMA/LABA therapy is more likely to provide patients and the healthcare community with a more effective therapy for only a marginal increase in cost3. When treating COPD patients, it is essential to optimise their treatment. Evidence suggests that LAMA/LABA can provide better patient outcomes than LAMA or LABA monotherapy4 therefore it is important to regularly assess patients receiving monotherapy and optimise treatment where needed.

COPD: LAMA/LABA as initial maintenance therapy for appropriate symptomatic patients


In the video above, Dr Daryl Freeman discusses LAMA/LABAs as initial maintenance therapies in COPD patients.

Management of COPD undergone an evolution in the last 30 years2,5. In 1997, when the first British Thoracic Society (BTS) Guideline was published, pulmonary rehabilitation was in its infancy and treatment mainly focussed on short acting bronchodilators and beta-2 agonists, anti-cholinergics and inhaled steroids5.

Dr Daryl Freeman discusses how, today, we have specific treatments licenced for COPD and pulmonary rehabilitation that has been established as an effective management tool for patients2. She believes that specialist clinics and specialist healthcare professionals have helped to drive an increased interest in optimising inhaled therapies within the broader field for patients with COPD.

Dr Freeman states that while some healthcare professionals do specialise in COPD, there are many generalist professionals who help to manage COPD patients on a day to day basis. She therefore understands that evidence based guidelines are therefore key to ensuring a consistent and effective approach to care. 

Dr Freeman talks about how the National Institute for Health and Care Excellence (NICE) Guideline is a simple, evidence based and a brilliant option for non-specialist healthcare professionals to ensure that they are providing the right care for their COPD patients. It covers a complete set of recommendations covering diagnosis, lifestyle issues, pulmonary rehabilitation and deciding on appropriate pharmacological intervention2.

Dr Daryl Freeman sees how LAMA/LABA combination therapy has been shown to improve patient outcomes when compared to monotherapy1. However, she believes that this combination is not just beneficial for patients. For healthcare professionals who many not have a specific interest in respiratory disease, offering a single effective inhaler as a pharmacological intervention can make managing patients simple and straightforward.

Prescribing Information

1. Anoro ▼ (umeclidinium/vilanterol) Prescribing Information
2. Incruse ▼ (umeclidinium bromide) Prescribing Information
3. Ventolin (salbutamol) Prescribing Information
4. Serevent (salmeterol) Prescribing Information

References

1. Global Initiative for Chronic Obstructive Disease, (2020). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. Available at https://goldcopd.org/wp-content/uploads/2019/12/GOLD-2020-FINAL-ver1.2-03Dec19_WMV.pdf [Accessed June 2020]
2. NICE, (2019). Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng115 [Accessed June 2020]
3. NICE, (2018) Chronic obstructive disease in over 16s: diagnosis and management [H] economic model report. Available at: https://www.nice.org.uk/guidance/ng115/evidence/h-economic-model-report-pdf-6602768757 [Accessed June 2020]
4. Beyond lung function in COPD management: effectiveness of LABA/LAMA combination therapy on patient-centred outcomes. Van der Molen T, Cazzola M. Prim Care Respir J. 2012;21(1):101-108 doi:10.4104/pcrj.2011.00102
5. BTS Guidelines for the Management of Chronic Obstructive Pulmonary Disease. Thorax 1997 Dec 52(Suppl 5): 1-1. Available from: https://thorax.bmj.com/content/52/suppl_5/1.long. [Accessed June, 2020]

PM-GB-CPU-WCNT-200007 August 2020

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